Thin It to Win It: Competition in Eating Disorder Treatment

When you have an eating disorder (particularly anorexia), people react in one of two ways. Either they want to get you help– or they’re jealous. Obviously, the latter group has some issues of its own. Patients still, however, take in those reactions. It’s everything from, “Wow, I wish I had that much self-control,” to “My goodness you’re so tiny!” or worse, “Tell me how you do it.” The most damaging part of these comments? They don’t stop at the threshold to treatment.

Whether you attend group therapy, intensive outpatient, or especially inpatient/residential treatment, the competition and the comments still happen. We eating disorder patients like to believe (as do our loved ones) that negative body-talk ends when you show up for therapy. Unfortunately, this is usually not the case.

What I really want to focus on is how this takes place in residential treatment settings. From my own experiences and those of others, it seems that there’s a much higher incidence of this sort of competition and negativity on adolescent units than adults’. I think this has a lot to do with the fact that the vast majority of adolescent girls in eating disorder treatment are not there voluntarily. There were put there by parents and doctors and therapists who are, according to them, taking away the only thing that they have any say over, the only thing that belongs to them. So many of these girls stage underground mutinies, banding together in subversion of the system, helping each other dodge rules and restrictions and staff. And while this creates a great deal of comradery, it has the unfortunate effect of keeping everyone sick. Because on the other side of the wall are a bunch of very sad, frightened little girls, consumed by shame, self-hatred, and guilt. And at the same time that they are acting like a team they are also competing to be the thinnest, the sickest, the best at this disease.

I don’t think this gets talked about enough. We often hear about pro-anorexia web sites and models who got airbrushed on magazine covers; what we don’t often think of is the influence other patients have on us in treatment. The first few times I went to group therapy and intensive outpatient the only thing I got out of it was an array of new eating disorder tricks. I constantly compared my body to the others in the group (even the therapists!) and never stopped obsessing about whether or not they were judging me for not being thin enough or sick enough to “deserve” treatment. During my first experience in a residential treatment center (RTC), my two roommates and I developed a late night calisthenics routine that we did after lights out, trying to see who could go the longest before their meds kicked in. One of those roommates asked me to teach her how to throw up. (That, I refused to do, knowing it would only open the door to a whole new kind of hell she would eventually have to escape from. If she got there on her own, whatever. But I was not going to be responsible for helping someone go there.) Needless to say, recovery did not even get a foothold there. It was like this in all the adolescent units I visited. Every now and then one of us would get a grip and go, Come on, guys, I’m really trying to eat here, or Maybe you should listen to your therapist, and everyone would feel kind of guilty and it would quiet down…for a little while. Then people would start to get anxious again and it would go right back to the way it was: everyone outwardly cooperating, while secretly judging each other and themselves for not being good enough.

Things work a little differently in adult RTCs. And again, I believe the major factor is whether or not you’re there on a voluntary basis. There also seems to a connection between programs that are located in medical hospitals as opposed to those that are located in houses, etc.; in my experience there is more noncompliance and competition and negativity in hospital environments than in others. (Note: This is just my experience and may be a gross generalization.) Whatever the program’s location, from what I’ve seen the same sort of things that happen on adolescent units still happen on adults’, just much less. People in adult programs are mostly there because they’re sick and they know it and it was either go to treatment or die and they didn’t want to die so they went to treatment. Most of these people are still ambivalent about recovery. There are others who are totally ready for it, and still others who just felt forced to come and don’t care at all. This can create some interesting group dynamics that are much more complex than those of the adolescents’ milieu. Mostly I think the competition and judging is reduced to everyone’s’ heads and journals and individual therapists; we patients are still constantly over analyzing, judging, and worrying about being judged. We are still wanting to be the thinnest, we still compare bodies; we just don’t do it as openly anymore. We are more aware of the fact that some people really are trying to recover. A lot of that is because we are no longer teenagers, who are genetically programmed to be egocentric. Still, we are all worried we are not sick enough, not good enough, not enough period.

What lies beneath this competition is more than just insecurity. That feeling, that fear of not being sick enough, is not about vanity or rivalry; it’s about feeling so worthless that you don’t believe you deserve to be cared for. That’s what it comes down to. People with anorexia and bulimia don’t believe that they deserve help, deserve rest, deserve to ask for what they need. In other words, they don’t believe they get to be human. And when they compete with each other to be the thinnest, the sickest, what they’re really doing is trying to prove that they’re worthy to be in treatment; worthy of the time and energy of the staff; worthy to nourish their bodies, worthy to start to heal. There are some places that address the issue of competition among peers and that is to be commended. I wish more of that would happen. Because the more it is brought out into the open, the more we patients can focus our energy on fighting our eating disorders– instead of each other.

© Sarah Henderson 2010

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  • nazza

    I appreciate your story and perspective. Though I am fortunate to have not suffered with an eating disorder, I recall many hospitalizations for bipolar where it seemed like the other patients around me were sicker than me. Group therapy sessions with extremely depressed people are rarely uplifting. Had I been seeking out new ways of trying to end my life by my own hands, I’m sure I could have found them as well.

    Sometimes patients are voluntarily committed and sometimes they are involuntarily committed when a court petition insists they be hospitalized for their own good. The difference between eating disorder patients and psychiatric patients is that the involuntary patients often are the absolute sickest. Many of them are psychotic, which means “out of touch with reality”, not “borderline axe murderer”.

    I’m talking mostly about adult units here. I do agree that adolescent units, for whatever reason, are very different. There’s a lot of commonality present in one place, which as you noted isn’t always a good thing. In some ways it’s like a surrogate high school. Teenagers do tend to be impulsive, and I say that as a former teenager looking back, not as an adult waggling a finger of critique. I was once in a hospital that had ED patients, mostly teenage girls, along with those struggling with mental illness and/or substance abuse. Isolated completely from the rest of us, it was quite evident they were a cliquish, tight-knit bunch, even when noticed from across the lunchroom at lunchtime meals.

    Though I have never told this story before, my first hospitalization for depression saw me smuggling in a cigarette lighter to the unit and setting fire to one of my shirts. I think it was a gesture of defiance and nowadays, I’d never think to do it again.

    I agree also with your conclusion. We are all fighting to seem worthy and to prove our mettle, which is true for ED patients and average people. If we could ever get to the point that who we are, whatever we are, didn’t need to be held up to group scrutiny to be proven acceptable, then we’d really be on our way to lasting health.

  • lklouise

    Thank you for your story, and I’m so sorry you’ve struggled with an eating disorder. I think talking about the negative unit environments on adolescent units is something that needs to be discussed, though I disagree with your assumption of adolescent egocentrism as the cause of continued treatment refusal or triggering other patients attempted recovery. And in my experience, I think you’re seriously right about environmental differences in hospital/locked down units verses houses/ open campus recovery centers. Patient Resistant treatment, and youth centered treatment as well, needs to be remodeled from the core up.

    This really struck a chord with me. I’ve watched most of my friends and a fair number of cousins go through this revolving door. Now that we’re in our mid-twenties, those who haven’t found a working recovery yet are so terrified of their experiences as youth that even if they want help, they know what happened back then wasn’t, and it’s really prohibited a lot of them from being able to ask.

    I spent a good deal of my youth in RTCs and hospitalized due to PTSD and the depression/anhedonia that developed with it. I left my last RTC in May 2003, so it’s been a while. While I did not have the generalized eating disorder mentality (or an eating disorder), I was emaciated (among other signs of basic functioning I couldn’t perform: getting out of bed, speaking or showering), and at one point a particularly stupid hospital threw me to an adolescent unit that was largely eating disordered teens (needless to say it took a caseworker all of 2 sessions to decide I was in the wrong place). But it was an experience.

    The level of control many of the adolescent units attempted was counterintuitive to any humanizing treatment experience. While yes, like many self-destructive coping mechanisms, a level of manipulation in order to maintain the only thing that makes you feel save is NATURAL and expected; while it should be overcome, that doesn’t happen through breaking somebody, and we shouldn’t try to. Some teens were mindblowingly manipulative and dedicated to their destruction, in stories I’ll remember forever. I’ve heard the phrase “If I don’t eat, they have to listen to me.” But what kind of 15 year old feels (whether rightly or wrongly is irrelevant here) they can’t be listened to until near dead? But the response- locking the teenager up, feeding them, drugging them and then MAYBE (if you lucked out on insurance or treatment program) earnestly beginning talk therapy, you’ve kind of already missed the point and the irrational teen has actually called the outcome- because it’s irrational as well!
    These teens are hurting; they are actively trying to slowly kill themselves while in a hospital. That lack of basic rationality excludes “generation me” narcissism from the list of culprits. It also doesn’t fit with the narrative upheld by a great many eating disorder pathologies: feeling like you are “too much” is a common phrase I’ve heard by those with binge/purging disorders.

    I’m not saying we shouldn’t require medical treatment of severely ill teens who have a great opportunity to get better, but I am tired of people being so incredibly callous/dismissive towards the mentality youth. It’s this idea of confirming that yes, they do not own themselves in any capacity, nor do we think them capable of that offends me. Yeah, of course those teenagers don’t feel they are human or they deserve to be human. And in response to that, RTCs and “behavior modification programs” institute terrible point/level system that very clearly tells them they’re not human. For example, one of my facilities (that had eating disorder patients integrated into my unit) had NUMBERS. We were numbers labeled on every item, engraved on every piece of allowed jewelry, written on every paper, called out at every line up.

    To say it’s immature to “act out” in that situation – it’s the only way many have of claiming autonomy at all, no matter the age group. I think the long history of forced institutionalization of adult women, minorities, the disabled and in our own culture of prisons makes that very clear. Dismissing sick teenagers valid complaints with the phrase “according to them” is also something to be aware of. There are a lot of “according to them” statements which are used to dismiss the complaints of different underclasses. I feel you are close to blaming the teenagers here for reacting in a rational way- finding friends while in a terrible situation (although the complicating factor of the diseases in common makes this rationality dangerous) and telling them to “suffer through the rules” rather than to tell the programs, treatment teams and families to be the actual adults and find real solutions.

  • natasha

    I had anorexia when I was fourteen. I got treatment in the same year it developed, I feel very fortunate for that. I guess the time of my disease eating away at me (no pun intended) with no outside interference was about six months.

    I had already had other health problems though, and my health went even further downhill … fast. When my doctors examined me, saw that I lost so much weight so quickly they revealed to me and my mother that I had anorexia. We already knew I had a problem with eating but we were unfamiliar with actual disorders. My mom had previously just nagged and nagged at me to eat, not knowing what to do.

    My doctors told me I needed help. They didn’t put me inpatient, on the condition that they have proof from my mom that I was eating more, and would check to make sure I was gaining weight at each visit. I realized that it was either eat or die, or be in a rehab, and I decided to eat. At first I hated myself, but strangely relief came and guilt left. I stopped feeling guilty because I was essentially being forced, and it wasn’t my choice and that made me feel better about eating. It was sick to feel that way, but in the end, it helped. I was given individual therapy specifically to avoid competition and I’m grateful for that. I don’t think I would have recovered as well as I did if not for that.

    I’m sure that there are benefits to group therapy, being able to talk to others who feel the same ways that you do must have a different effect than a therapist. It would help to know you’re not weird or alone in your problems. But it clearly has the aforementioned drawbacks, and I think as a fourteen year old, my doctors made the right call. I think it is good for some, maybe not for others. Doctors should take their time analyzing the best treatment methods for individuals, which I was fortunate enough to have received.